Healthcare Provider Details

I. General information

NPI: 1033875240
Provider Name (Legal Business Name): KAYLA WICKS CPO, LPO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 HUDSON ST STE 105
LONGVIEW WA
98632-3046
US

IV. Provider business mailing address

830 GISH RD
ONALASKA WA
98570-9529
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-6049
  • Fax:
Mailing address:
  • Phone: 253-797-5163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS61132736
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOI61230221
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: